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Reflective practice is a key aspect of Nursing Management and is guided by specific models of reflection. These models act as a framework within which nursing professionals can work. Additionally, it can also be considered as a learning model that serves the rationale of a profession and is predominantly linked to the field of health sciences. The practices based on Reflective approaches emphasize on the importance of learning through experiences following the thinking process and correlates the realistic experiences with the speculative learning approaches. Among the various different models of reflection, Gibb's Model strengthens upon the event and includes a critical description of situational happenings together with a reflection of perceptions and feelings persisted at that time upon being in to the state or situation. Subsequently, the nursing professional personally evaluates the nature of experience in a way that was been good or bad and thereby analyses if she can create any sense to the situation (Atkins, Murphy 1994).
Within this essay, the described case study reflects on the ward manager who possessed minimal confidence at the time of assessment owing to the internal anxiety as well as the leadership pressure and lack of knowledge. In addition, this essay discusses several concerns pertaining to nursing practice and provides an insight to the potential importance of like history taking process and physical assessment. The Ward manager must understand the following principles of history taking process:
Obtaining a history about health is a conversation that underlines a specific purpose. Unlike social discussions where in which we express the needs and interests with a responsibility only for ourselves, the primary goal of a nursing professional is the patient interview (carried out for the well-being of the patient) (Bickley, 2009). The underpinning ideology of history taking process is to establish a supportive and trust worthy relationship, gather and to offer information. It must be understood that the basic communication skills are essentially needed in order to maintain an effective rapport between the patient and therapist. The specific communication strategy of maintaining an open, reverent and inquisitive attitude (in questioning pattern) play a crucial role in enhancing the communication process, establishing trust and rapport together with the willingness of the patient in teaching to the history taker. But these strategies tend to exhibit difficulties during the coding process, especially when numerous answers were provided. The strategy of collaborative partnerships with the communication that is dependent on trust, respect and a willingness to reconsider assumptions assist in enabling patients to express concerns that run oppositely to the dominant culture. But these approaches cannot be applied to the limited number of population and it completely depends upon the interest of the patient. Nevertheless, the principles laid down by Tavistock (Rights, Balance, Comprehensiveness, Cooperation, Improvement, Safety and Openness) including other communication strategies guide the behaviour of individuals and the questioning patterns within healthcare.
The critical knowledge about anatomical landmarks is definitely needed for any Ward Manager, prior to physical assessment process. These landmarks include hair (surface, allocation, scalp and critters), Nails and Skin (the assessor must know the terminology, diagrams and pictures of various layers). The HEENT (Head, Eyes, Ears, Nose, Mouse and Throat) system, Thorax and Lung portions, the BREEK that involves breathe sounds, respiratory warning signs and terminologies as well as the video graphical picture of lungs and breast region to analyse the alveolar and blood vessel distribution (Hopcroft, Forte 2007). Additionally, the physical assessment skills play a crucial role identification and management of actual and potential health problems, evaluating the efficacy of nursing care, promoting the nurse patient relationships, making clinical judgements and developing, establishing the data that aid in the evolution of future nursing phases and practices (Jarvis, 2007). Though patient history is subjective, the physical assessment process is an objective study that starts with a general survey. Each part of the body that was reviewed has a nursing history during the initiation of objective exam procedure (Bickley, 2009).
However, the ward manager must develop following strategies to ensure the quality within the physical assessment process. These comprise of asking open ended questions, listening cautiously and unwearyingly to the patient story, keeping an eye on physical findings, patient's story, designing a methodical and organized sequence of physical examination and history taking process, evaluating mistakes in data compilation and construal techniques, conferring with the ward colleagues and reviewing the medical literature to clarify the potential uncertainties and finally applying principles of evidence based data analysis and practice within patient information and setting (Clark, Walsh 1999). On the other hand, the Ward manager must understand certain principles that govern the physical assessment. The selected assessments have to be valid, reliable and consistent. It must be highly specific and should identify the percentage of people who assessed negative among the group of people with no-diseased conditions (Cross, Rimmer 2002). Additionally, the principle of predictive value that indicates the reliability of the symptom (in examining the presence or absence of the disease) must also be conferred and the probability of true negatives out of the total population count need to be tested (Johns, 1995). Lastly, the test processes have to maintain sensitivity in a way by analysing the proportion of people with true positives and false negatives among the various groups of people under study (Higgins, 2007).
Within the occupational health environments, tests are generally performed to minimise the work risks and to control the identified health complexities. The performed diagnostic tests include blood tests (Complete Blood Picture), breathing tests, heart rate and blood pressure monitoring, genetic and AIDS testing through specimen analysis (examples include stool test for occult blood, Tuberculosis testing and collecting blood samples for HIV and other sexual disease screening) (Higgins, 2007; Johns 1995). Furthermore, numerous diagnostic tests may be carried out on a regular basis depending upon the diseased condition of the patient. It is very important for the Ward Manager (who is carrying out the assessment) to understand the reference and the normal values of these diagnostic tests (Thibodeau, Patton 2006). The process of interpretation must be performed within the state of patient well being context and assessor must understand that specific circumstances like hydration, mental status, fasting, nutrition and flexibility with the test etiquettes are the some of the influential factors that affect the test outcomes. The interferences due to alcohol and drug consumption, physical exercise, foods and beverages including diurnal and other cyclic variations must be analysed by the Ward Manager. This can seem to be possible only when he/she possess profound knowledge about pharmacology and physiology of the patient and exhibition of such knowledge is definitely needed to identify the patient's state and condition (Bickley, 2009).
In addition, the issues of Nonmaleficence (considered as not doing any harm or stated as "First, do no harm"). Beneficence that dictates the assessor in doing good for the patient must be followed. The specific actions of the clinicians need to be encouraged by what is within the patient's best interest (Thibodeau, Patton 2006). Autonomy where in which the patients possess a right to choose their own best interest must be governed by the Ward Manager as a part of professionalism. The patient data must be maintained in a high confidential manner and should not be disclosed to anyone unless specific circumstances persist. The assessor need to enable the patient in explaining openly about his condition and should not be interrupted. In diagnosing mentally challenged patients, the ward manager need to give prime importance to the "Informed Consent", an essential legal, professional and ethical issue that exercise the decision making capacity and treatment procedures (Fairley, 2005). During emergency situations, where consent cannot be acquired, the treatment must be provided for any patient who need it and such treatment must be limited in a way that is instantaneously necessary to protect life and to prevent deterioration in patient's health. This is the principle of necessity and it must be executed as a part of nursing profession (Higgins, 2007).
In carrying out a physical assessment to the patient, the Ward Manager utilizes two different approaches, Head to Toe assessment (also called as Cephalocaudal approach) and Body systems approach. The first strategy involves examining the patient from top of the body to the toe portion (Schon, 1993). This type of assessment used in data collection aids to thwart overlooking of certain aspects in data collection process, minimizes the positional changes required and consumes less time as the nurse avoids periodical movements around the client. But this strategy may not ease the problem identification process. Towards the other side, the body system strategy includes collection of relevant data in accordance to the well-designed systems of the body. Further, it involves structural examination of each system with an aim to obtain clustered findings and disease identification (Bickley, 2009). Nevertheless, this approach may create tiresomeness to the patient and nurse owing to frequent positional changes. Additionally, this approach enables the nurse or the assessor in examining the body parts repeatedly and thereby devour more time. With relation to the present case study, it is highly necessary for the ward manager to gain sufficient knowledge on underlying principles of two strategies and I suggest he/she should implement the specific approach depending upon the patient condition, time and the proposed treatment (Bickley, 2009).
If I was given a role in performing physical assessment, I would divide the patient body in to six general areas: head and neck, chest, abdomen, extremities, genitalia, anus and rectum. The findings obtained will be conferred for high accuracy as they critically depend upon specific techniques employed as well as on the structures identified (Jarvis, 2007). Additionally, the mental status assessment will be performed as a part of my role as this help would me in obtaining information about the level of patient's organic functioning, attention, memory, abstract thinking ability. Each patient is assessed in a Cephalocaudal manner and the data obtained was documented carefully as it is important in the objective assessment (physical assessment) process (Cross, Rimmer 2002). Additionally, I will correlate the information present in preliminary test reports with the objective assessment data to identify the exact aetiology of the disease. The knowledge gained with relation to the reference and normal values will be applied within the treatment practice to understand the critical effect of prevailing imbalances. The patient will be assessed in a confident manner without any interference of anxiety and depression. The knowledge gained through the pharmacological and physiological perspectives was utilised to evaluate the disease and its deleterious effects on body systems. Following the analytical interpretations, the patient is then prescribed with the medication that suits with the disease condition. The total patient report signifying his name, identified medical problem, tests, findings and the treatment plan proposed will be documented for future reference (Bickley, 2009).
Apart from these, various inter professional working barriers optimise the health care profession as well as the assessment process. These include professional jealousies, impractical expectations of others, confusion ambiguity about the role, professional attitudes towards one another, leadership responsibilities, anxiety, depression and lack of knowledge and several others. To enable an effective working relationship in nursing practice, it is very important to address these issues (Gustafsson, Fagerberg 2004). Among various factors depicted above, Leadership is the important issue and good leadership is essentially needed to enable efficient and effective decision making processes and assessments. The study by Clouder and Sellars (2004) identified that there may be nervousness for nurses and ward managers between their traditional role of care and rehabilitation therapy that demands standing back and encouraging independence. Introducing sudden responsibilities upon the nurses in a way by moving them from comfort zone (of taking care of patients) may increase their work load and this eventually leads in inappropriate assessment (Clouder, Sellars 2004). In order to demonstrate high expertise within the health care practice, nurses must possess essential skills related to therapeutic practice, coordination, empowerment and advocacy, education, clinical reasoning and governance, political awareness and advice or counselling techniques (Clouder, Sellars 2004).
Today, the National and International Organisations in various countries have recognised the health promotional strategies for physical assessment process. Current concepts of these strategies include detection and prevention of disease through active promotion of well-being and quality of life, in-depth understanding of physical, cognitive, emotional and social factors that underline the disease process and addressing such factors with the use of sophisticated methodologies. Additionally, the patients must be advised about the various developmental strategies and an integrated explanation should be provided on the physical findings with health promotion (Somerville, Keeling 2004). When diagnosing children, the nurse must advise their parents about various developmental strategies, immunisation schedules, screening procedures that aid in their child development process. It must be understood that in order to achieve a healthier world, every health care professional must broadly emphasise on comprehensive health promotional strategies during childhood as their ultimate future depends upon the implementation of these approaches.
The present case study upon the Ward manager who was ineffective in carrying out assessment owing to depression, anxiety and leadership was effectively demonstrated along with the strategies that are needed to be followed to tackle such conditions. The manager was recommended to gain knowledge about pharmacological, physiological and anatomical perspectives. Lastly, I would advise the Ward manager to repeatedly practice Gibbs model of reflection, in a way by completing an exercise that provide an elaborate description of events, feelings, good and bad experiences and thereby analysing the responses practically to the situation under study.